Diagnosis of heart failure is too late. Symptoms of heart failure are non-specific. Brain natriuretic peptides allow the diagnosis of heart failure in pauci-symptomatic patients, with a threshold of ...35pg/mL for BNP and 125pg/mL for NT-proBNP. Left ventricular dysfunction, either diastolic or systolic, remains asymptomatic for a long time. In diabetic and/or hypertensive patients, natriuretic peptides, can be used to diagnose asymptomatic left ventricular dysfunction, with a threshold of 125pg/mL NT-proBNP. Treatment blocking the renin-angiotensin-aldosterone system in diabetic patients with NT-proBNP levels of 125pg/mL can prevent onset of heart failure. Screening of subjects at risk of heart failure (diabetics, hypertensive) is possible thanks to natriuretic peptides.
Diagnosing immune-mediated myocarditis is challenging because of non-specific clinical signs and symptoms. Cardiac magnetic resonance imaging (CMR) provides subepicardial late gadolinium enhancement ...(LGE) in the setting of acute myocarditis, but the diagnostic value of LGE pattern for differentiating between immune-mediated and viral-related aetiologies remains unknown.
To determine the value of LGE pattern for differentiating between immune-mediated and viral-related aetiologies in patients with acute myocarditis.
One hundred and five patients with acute myocarditis who underwent CMR, including LGE variables, were included retrospectively. Viral-related aetiology was retained with a negative autoimmune and autoinflammatory assessment at diagnosis and 6-month follow-up.
Aetiology was immune-mediated in 31 patients and viral-related in 74 patients. Patients with immune-mediated myocarditis were older (55±16 vs. 31±12years; P<0.001) and more likely to be female (52% vs. 14%; P<0.001) than those with viral-related myocarditis. There was no difference in left ventricular ejection fraction between the immune-mediated and viral-related myocarditis groups (53±15% vs. 57±8%; P=0.61). Regarding LGE, patients with viral-related myocarditis were more likely to have basal anteroseptal, mid anteroseptal, mid anterior and basal anterolateral location. Patients with immune-mediated myocarditis were more likely to have apical septal, apical inferior, apical lateral, mid anterolateral and basal inferior location. Segments with difference in prevalence of LGE between aetiologies were summed to build a score where positive significant association with immune-mediated myocarditis was quoted 1 and positive significant association with viral-related myocarditis was quoted −1. A score≥0 differentiated immune-mediated from viral-related myocarditis with 94% sensitivity and 77% specificity (area under the receiver operating characteristic curve 0.88; P<0.001).
CMR provides arguments for differentiating immune-mediated from viral-related acute myocarditis by showing preferential LGE localization in apical septal, apical inferior, apical lateral and basal inferior segments.
Le diagnostic de la myocardite dysimmunitaire (MD) est difficile en raison de symptômes et signes cliniques aspécifiques. L’imagerie par résonance magnétique (IRM) cardiaque fourni un rehaussement tardif (RT) sous-épicardique du gadolinium dans le diagnostic de myocardite aiguë, mais la valeur diagnostique RT pour la différenciation des MD et virales (MV) demeure inconnue.
Cette étude vise à déterminer la valeur du RT dans la différenciation les MD et MV chez les patients atteints de myocardite aiguë.
Cent cinq patients atteints d’une myocardite aiguë ayant eu une IRM cardiaque avec RT ont été inclus rétrospectivement. Le diagnostic de MV a été retenu au décours d’une évaluation auto-immune et auto-inflammatoire négative au diagnostic et au suivi à 6 mois.
Le diagnostic de MD et de MV a été retenu chez 31 et 74 patients, respectivement. Les patients atteints de MD étaient plus âgés (55±16 contre 31±12 ans ; p<0,001) et plus susceptibles d’être des femmes (52 % contre 14 % ; p<0,001) que ceux atteints de MV. Il n’y avait pas de différence entre les MD et les MV en termes de fraction d’éjection du ventricule gauche (53±15 % contre 57±8 % ; p=0,61). En ce qui concerne le RT, les patients atteints de MV étaient plus susceptibles d’avoir une localisation antéro-septale basale, antéro-septale médiane, antérieure médiane et antéro-latérale basale que ceux atteints de MD. Les patients atteints de MD étaient plus susceptibles d’avoir une localisation septale apicale, inférieure apicale, latérale apicale, antéro-latérale médiane et inférieure basale que ceux atteints de MV. Les segments présentant une différence de prévalence de RT entre les étiologies ont été additionnés pour obtenir un score où une association positive avec la MD a été cotée 1 et une association positive avec la MV, −1. Un score≥0 différencie la MD de la MV avec une sensibilité de 94 % et une spécificité de 77 % (aire sous la courbe ROC 0,88 ; p<0,001).
L’IRM cardiaque fournit des arguments pour différencier les MD des MV en montrant une localisation préférentielle du RT en regard des segments septo-apical, inféro-apical, latéro-apical et inféro-basal.
Background
Right ventricular (RV) function is a powerful independent predictor of adverse heart failure outcomes. The aim of this study was to compare the predictive value of main RV systolic imaging ...parameters for outcome.
Methods
Seventy‐nine patients underwent comprehensive cardiovascular imaging modalities including transthoracic echocardiography, cardiac magnetic resonance (CMR) imaging, and tomographic equilibrium radionuclide ventriculography (ERV) for the assessment of RV function. The composite primary endpoint (CPE) was defined by the occurrence of death, heart transplantation, implantation of a left ventricular assist device, or new‐onset acute heart failure.
Results
During a mean follow‐up of 13 ± 9 months, 15 (19%) patients reached the CPE. The areas under the receiver operator characteristic curves for the prediction of the CPE were 0.922 (P < .001), 0.913 (P < .001), 0.906 (P < .001), 0.849 (P = .002), 0.837 (P = .003), 0.799 (P = .009), 0.792 (P = .011), 0.753 (P = .026), 0.720 (P = .053), and 0.608 (P = .346) for integral systolic S’ wave tricuspid annular velocity, RV free wall longitudinal strain (RVFWLS), RV fractional area change, tricuspid annular plane systolic excursion, RV ejection fraction (RVEF) by CMR using the 4‐chamber slices, peak systolic S’ wave tricuspid annular velocity, RVEF by CMR using short‐axis slices, RVEF by ERV, RV myocardial performance index, and RV myocardial acceleration during isovolumic contraction, respectively.
Conclusion
Echocardiographic parameters, and particularly integral systolic S’ wave tricuspid annular velocity and RVFWLS, have the best prognostic performance.
Few data are available on the application of transoesophageal echocardiography (TOE) recommendations in daily practice.
To evaluate TOE practice based on echocardiography societies’ guidelines, and ...to determine complication rates and factors associated with patient feelings.
Between April and June 2017, we prospectively included all consecutive patients referred to 14 French hospitals for a transoesophageal echocardiogram (TOE). A survey was taken just after the examination, which included questions about pre-procedural anxiety, and any pain, unpleasant feeling or breathing difficulties experienced during the examination.
Overall, 1718 TOEs were performed, mainly for stroke evaluation. A standardized operating procedure checklist was completed in half of the patients before the examination. TOE was unpleasant for 62.4% of patients, but was stopped for agitation or intolerance in 3.5 and 1.4% of cases, respectively. We observed one severe complication (pulmonary oedema). The mean TOE duration was short (9.2±4.6minutes), but was longer with residents than with more experienced physicians (11±4.7 vs. 8.8±4.7minutes for junior physicians P=0.0027; vs. 8.9±4.8minutes for senior physicians P=0.0013; and vs. 7.5±4.1minutes for associate professors/professors P<0.0001). The visual analogue scale (VAS) score after TOE was good (8.3±1.7 out of 10), and was better in patients with general anaesthesia (GA) than in those without GA (9.3±0.9 vs. 8.1±1.7; P<0.0001). In patients without GA, the VAS score was similar with and without local anaesthesia (8.1±1.7 vs. 8.2±1.6; P=0.19). After multivariable adjustment, absence of anxiety before TOE and greater operator experience were consistently associated with a higher VAS score.
TOE is safe, with a low rate of complications and few stops for intolerance. A shorter TOE duration and better patient feelings were observed for experienced operators, highlighting the importance of the learning curve, and paving the way for teaching on a TOE simulator.
Il existe peu de données sur l’application des recommandations sur l’échocardiographie transoesophagienne (ETO) en pratique quotidienne.
Évaluer la pratique de l’ETO selon les recommandations des sociétés savantes d’échocardiographie et déterminer le taux de complications et les facteurs associés au ressenti du patient.
Entre avril et juin 2017, nous avons inclus prospectivement tous les patients adressés pour une ETO dans 14 hôpitaux français. Une enquête a été réalisée juste après l’examen afin d’évaluer l’anxiété avant la procédure, la douleur, les sensations désagréables ou les difficultés respiratoires ressenties pendant l’examen.
Au total 1718 ETO ont été réalisées, principalement pour l’évaluation d’accidents vasculaires cérébraux. Une checklist standardisée a été réalisée chez la moitié des patients avant l’examen. L’ETO était considérée comme désagréable chez 62,4 % des patients, mais elle n’a été arrêtée pour une agitation ou une intolérance que dans 3,5 et 1,4 % des cas, respectivement. Nous avons observé une complication sévère (œdème pulmonaire). La durée moyenne de l’ETO était courte (9,2±4,6minutes) mais plus longue chez les internes que chez les médecins plus expérimentés (11±4,7 vs. 8,8±4,7minutes pour les chefs de cliniques p=0,0001 ; vs. 8,9±4,8minutes pour les praticiens hospitaliers p=0,0013 ; et vs. 7,5±4,1 minutes pour les maîtres de conférences et professeurs des universités p<0,0001). Après l’examen, la note de l’échelle visuelle analogique (EVA) était bonne (8,3±1,7 sur 10), meilleure chez les patients sous anesthésie générale (AG) que sans AG (9,3±0,9 vs. 8,1±1,7 ; p<0,0001). Chez les patients sans AG, l’EVA était identique avec et sans anesthésie locale (8,1±1,7 vs. 8,2±1,6 ; p=0,19). Après un ajustement multivarié, l’absence d’anxiété avant l’ETO et une expérience plus importante de l’opérateur étaient indépendamment associés à une EVA plus élevée.
L’ETO est un examen sûr, avec un faible taux de complications et peu d’arrêts prématurés pour une intolérance. L’examen était plus court et mieux vécu lorsqu’il était pratiqué par un opérateur expérimenté, soulignant l’importance de la courbe d’apprentissage et ouvrant la voie à l’enseignement sur le simulateur d’échocardiographie.
BackgroundEstimation of left ventricular filling pressures (LVFP) is a determining factor in the follow-up of patients with cardiac amyloidosis (CA). Natriuretic peptides (NPs) and tissue Doppler ...imaging may be used to monitor LVFP in patients with CA. The aim of this study was to evaluate the value of NPs and Doppler parameters in estimating LVFP in patients with CA.MethodsFifty patients with biopsy-verified light chain (n=31), A protein amyloidosis (AA) (n=1), apoliporotein A2 (n=1) or bone scintigraphy-proven transthyretin (n=17) CA were retrospectively included. All patients underwent right heart catheterisation (RHC). Among them, 48 (96%) and 43 (86%) had assays of NPs (20 brain natriuretic peptide (BNP), 27 N-terminal pro-hormone brain natriuretic peptide (NT-proBNP) and 1 both) and transthoracic echocardiography performed within 24 hours of RHC, respectively.ResultsThe median BNP and NT-proBNP levels were 1000 (243–1477) ng/L and 10 106 (2935–13 348) ng/L, respectively. Echocardiography demonstrated left atrial enlargement with a mean volume of 47±16 mL and low tissue Doppler lateral Ea of 5±2 cm/s. The mean early diastolic mitral inflow velocity on early lateral mitral annular diastolic velocity ratio (E/Ea) ratio was 18±7, and the mean pulmonary capillary wedge pressure (PCWP) by RHC was 18±8 mm Hg. There was no correlation between BNP (r=0.260, p=0.774) or NT-proBNP (r=−0.103, p=0.984) levels and PCWP. There was a slight correlation between E/Ea ratio and PCWP (r=0.337, p=0.029). E/Ea ratio >14 performed poorly in differentiating elevated and low LVFP.ConclusionIn patients with CA, NPs do not accurately estimate PCWP. Tissue Doppler-derived mitral E/Ea ratio is correlated with PCWP, but the slight correlation requires to estimate LVFP in a broad clinical and imaging context to avoid diagnostic errors.
Chronic thromboembolic pulmonary hypertension (CTEPH) is a major cause of chronic pulmonary hypertension leading to right heart failure and death. Ventilation/perfusion single photon emission ...computed tomography (V/Q SPECT) is the screening test of choice showing mismatch in at least one segment or two sub-segments. Our aim was to investigate the relationship between the extent of pulmonary perfusion defects and hemodynamic, echocardiographic, biological and functional parameters. Between 2012 and 2019, 46 patients with CTEPH were retrospectively enrolled in the study. The diagnosis of pulmonary hypertension was made by the referral team of the expert center according to the European guidelines. All patients underwent pulmonary V/Q SPECT, right heart catheterization, transthoracic echocardiography (TTE), functional tests and natriuretic peptides assays. There was a slight correlation between the extent of pulmonary perfusion defects and pulmonary vascular resistances (R=0.510, P < 0.001). However, there was no correlation between the extent of pulmonary perfusion defects and NYHA stage, NT-proBNP level, functional parameters (6 minutes-walk distance-6 MWD), right ventricular function assessed by TTE. Pulmonary perfusion defects extension by V/Q lung SPECT are correlated with pulmonary vascular resistances in CTEPH. However, it is not correlated with right ventricular function and functional parameters.
We designed a two-part epidemiological study, an observatory for amyloid transthyretin amyloidosis (OBSAMYL). The first objective was to identify and count the number of patients diagnosed with ATTR ...amyloidosis in participating French centres. The second was to evaluate the use and safety profile of tafamidis meglumine in real-world settings.
This was a non-interventional descriptive retrospective multi-centre national study. A census was conducted to estimate the number of patients diagnosed with ATTR amyloidosis who were still alive at the time of the study (defined as 1 June 2017). Patients with ATTR amyloidosis were contacted by French centres from the French Rare Diseases network program. Patients aged ≥18 years with hereditary transthyretin-mediated amyloidosis (ATTRv) or wild-type transthyretin amyloidosis (ATTRwt) or a pathogenic transthyretin (TTR) mutation were eligible.
Of the 38 centres (13 cardiology and 25 neurology) invited to participate, 22 (60.5%) (10 cardiology, 12 neurology) participated. There were 333 patients in cardiology census population. Before diagnosis one-fourth of the patients had cardiac decompensation, and one-fifth had a pacemaker. The 177 ATTRwt-CM patients were older (80.1 ± 7.0 years versus 64.2 ± 14.3 years; P < 0.001), had a higher incidence of hypertension (51.4% versus 35.3%; P = 0.003), and a higher incidence of arrhythmia (45.8% versus 28.3%; P = 0.001) than 156 ATTRv patients. There were no differences in disease severity according to New York Heart Association classification. The ATTRv-mixed + CM group had more neurological symptoms (paraesthesia or dysesthesia, neuropathic pain, digestive disorders, and orthostatic hypotension) than the ATTRwt-CM group (P < 0.001). Biopsies were performed on nearly 90% of patients with most of them being positive. The most common biopsy sites were salivary glands (137 biopsies) and cardiac tissues (77 biopsies). Tafamidis meglumine was administered to 174 cardiology patients, including 96 with ATTRv-mixed, 61 with ATTRwt-CM, and 17 with ATTRv-CM. Tafamidis meglumine was generally well tolerated. 18 adverse events, including 12 severe adverse events were reported in 174 patients as safety-related incidents. Tafamidis meglumine was likely responsible for five adverse events, one of which was severe.
This study of real-world clinical ATTR amyloidosis cases in France further elucidated the characteristics of and diagnostic approach to a cardiology patient population census of 333 patients. As of June 1, 2017, 177 ATTRwt-CM, 117 ATTRv-mixed, and 39 ATTRv-CM patients were alive. Our experience with tafamidis meglumine in the cardiology population confirmed its good tolerance.
Wild-type transthyretin amyloidosis (ATTRwt amyloidosis) is primarily diagnosed in elderly men but diagnoses in younger patients and women have recently increased.
The purpose of this study was to ...examine age- and sex-related differences in patients with ATTRwt amyloidosis enrolled in the Transthyretin Amyloidosis Outcomes Survey (THAOS).
THAOS was a global, longitudinal, observational survey of patients with transthyretin amyloidosis, including both hereditary and wild-type disease, and asymptomatic carriers of pathogenic transthyretin gene variants. Patients characteristics at enrollment were analyzed by age at enrollment and sex (data cutoff date: August 1, 2022).
Of 1,251 patients with ATTRwt amyloidosis, 13.7%, 49.1%, 34.5%, and 2.8% were aged <70 years, 70 to 79 years, 80 to 89 years, and ≥90 years, respectively. The proportion of women increased with age, from 4.1% in patients aged <70 years to 14.3% in patients aged ≥90 years. In the respective age groups, median time from symptom onset to diagnosis overall (male, female) was 1.7 (1.3, 5.2), 2.0 (2.0, 2.2), 1.8 (1.9, 0.8), and 0.7 (0.6, 2.5) years. A Karnofsky Performance Status score ≤70 was observed in 17.1%, 30.1%, 46.1%, and 44.4% of patients aged <70 years, 70 to 79 years, 80 to 89 years, and ≥90 years, respectively.
In this THAOS analysis of patients with ATTRwt amyloidosis, patients were diagnosed an average of 2 years after symptom onset, with the greatest diagnostic delay in women aged <70 years at 5 years. Patients were predominantly men, but the proportion of women increased with age. A substantial proportion of patients had significant functional impairment regardless of age.
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